Nursing knowledge of the principles of self-care of heart failure in primary care: a multicentre study.

INTRODUCTION: Nurses play an important part in the education of patients with HF. To prepare patients with HF for self-care maintenance behaviours, nurses must have knowledge of basic self-care maintenance principles. AIM STUDY: The aim of this study was to determine the degree of knowledge of primary care (PC) nurses on the principles of self-management of HF and variables associated with this. METHODOLOGY: This is an observational, cross-sectional descriptive study, carried out in 2014, in the city of Barcelona (Catalonia). Nurses' Knowledge of Heart Failure Education Principles questionnaire (NKHFEP) was used to assess the principles of HF self-care education. Instrument items assess knowledge of nurses on 5 themes: diet, liquids/weight, worsening signs or symptoms, medication and exercise. Factors related to adequate knowledge were evaluated. RESULTS: Of 216 PC nurses, who completed the questionnaire, the average score was 15.6 (SD: 2.2). Only 36 (16.7%) obtained an adequate level of knowledge and defined as a score ≥ 18 points. In multivariate logistic regression, nurse factors associated with an adequate knowledge of principles of self-care of HF were having achieved a PhD degree (OR: 36.4, 95% CI: 2.8-468.2, p = 0.006) and previous specific training in HF (OR: 19.8, 95% CI: 1.4-279.3, p = 0.026). CONCLUSIONS: The degree of knowledge of PC nurses in the principles of self-care in HF was higher among nurses who had completed the doctorate and in nurses who had received specific training in HF.

What is the optimal cut-off threshold in self-home blood pressure measurement?: A cohort study according to STROBE statement.

Two aspects arise concerning the use of self-measured blood pressure monitoring to diagnose white-coat hypertension (WCH): the presence of target organ damage (TOD) and the normal cut-off threshold. This study aims to evaluate the cardiovascular risk of WCH according to different self-measured blood pressure normal cut-off thresholds and the influence of TOD at baseline.In all, 678 patients were followed for 6.2 years; 223 normotensive patients, 271 patients with sustained hypertension (HT), and 184 with WCH. TOD was defined as: left ventricular hypertrophy according to ECG, albuminuria, or low estimated glomerular filtration rate. The risk for different cutting points of self-measured blood pressure (<135/85 mm Hg, <130/85 mm Hg, and <130/80 mm Hg) has been determined.The patients with HT experienced an increase in cardiovascular risk and death higher than the normotensive patients (odds ratio [OR] 7.9, 95% confidence interval [CI] 3.8-16.2 for sustained HT; and OR 3.5, 95% CI 1.6-7.4 for WCH). This was observed for all the cut-off thresholds analyzed. In white-coat hypertensive patients (cut-off <135/85 mm Hg) with TOD, the risk was higher than in normotensive patients (OR 4.5; 95% CI 1.9-10.6). Using a self-monitoring blood pressure cut-off threshold of <130/80 mm Hg without TOD at baseline, the WCH cases exhibited no differences in risk to the normotensive patients (OR 2.0, 95% CI 0.5-7.7).The decisions being taken for patients with WCH based on the presence of TOD and a self-administered home monitoring blood pressure measurement cut-off point probably lower than the one that is currently recommended.

Improving ambulatory blood pressure monitoring knowledge in nurses and doctors: impact of a training intervention.

INTRODUCTION: Ambulatory blood pressure monitoring (ABPM) is fundamental to diagnosing and monitoring arterial hypertension (HTN), yet it is not known how effective training could be in improving knowledge of ABPM. PURPOSE: The purpose of this study was to evaluate ABPM knowledge before and after a training activity. METHODOLOGY: A before-and-after intervention study of 116 professionals. Data was collected on age, sex, occupational category, work setting, and work experience. ABPM knowledge was determined by a questionnaire to evaluate expertise in understanding and interpreting ABPM results. RESULTS: Multivariate regression analysis showed that, pre-intervention, having more than 20 years' experience (odds ratio (OR): 5.9; 95% confidence interval (CI): 1.3-33.9; p = 0.049) and being a doctor (OR: 5.7; 95% CI: 1.8-18.3; p = 0.004) were associated with greater ABPM knowledge. Training increased the number of professionals with adequate ABPM knowledge: 85.3% after training vs 26.7% before training. Training increased the questionnaire mean (SD) score by almost 3 (1.7) points: 9 (2.2) after training vs 6.3 (2.2) before training ( p < 0.05). Of the 116 professionals, 90.5% achieved a higher overall score after training. The impact of the intervention was greatest on women nurses older than 45 years and with more years of experience, employed in primary care, and with prior experience of ABPM. CONCLUSIONS: Knowledge of ABPM is deficient but can be easily improved by training that is most effective in primary care and among nurses.

Effect of effervescent paracetamol on blood pressure: a crossover randomized clinical trial.

OBJECTIVE: To evaluate the effect of effervescent paracetamol on office and ambulatory blood pressure (BP) compared with noneffervescent paracetamol in hypertensive patients. DESIGN: This was a multicenter open crossover randomized clinical trial. SETTING: Primary care centers in Catalonia and the Basque Country. PARTICIPANTS: Inclusion criteria were office BP 150/95 mmHg or less and daytime ambulatory BP 140/90 mmHg or less, stable pharmacologic or nonpharmacologic antihypertensive treatment, and concomitant chronic osteoarticular pain. INTERVENTIONS: Baseline randomized assignment to 3-week periods of effervescent paracetamol (1 g three times a day) first and noneffervescent paracetamol later, or inversely, during a 7-week study period. At the start and end of each treatment period, 24-h ambulatory BP monitoring was performed. MAIN OUTCOME MEASURES: Differences in 24-h SBP between baseline and end of both treatment periods. The main analyses were performed according to the intention-to-treat principle. RESULTS: In intention-to-treat analysis, 46 patients were analyzed, 21 were treated with paracetamol effervescent and noneffervescent later, and 25 followed the opposite sequence. The difference in 24-h SBP between the two treatments was 3.99 mmHg (95% confidence interval 1.35-6.63; P = 0.004), higher in the effervescent paracetamol treatment period. Similarly, the per-protocol analysis showed a difference in 24-h SBP between the two groups of 5.04 mmHg (95% confidence interval 1.80-8.28; P = 0.004), higher in the effervescent paracetamol treatment period. Self-reported pain levels did not differ between groups and did not vary by treatment period. No serious adverse events were reported in either study arm. CONCLUSION: Effervescent paracetamol tablets are responsible for a significant daytime and overall increase in ambulatory 24-h SBP. TRIAL REGISTRATION: NCT: 02514538 EudraCT: 2010-023485-53.

Evaluation of the relationship between effervescent paracetamol and blood pressure: clinical trial.

BACKGROUND: Paracetamol's solubility is achieved by adding to the excipient sodium salts, either as bicarbonate, carbonate or citrate. As the relationship between salt and hypertension is well known, due to the sodium content it has raised a hypothesis that may interfere with the control of that risk factor. Therefore, the objective of this study is to evaluate the effect on blood pressure of effervescent paracetamol compared to non-effervescent, in hypertensive patients. METHODS/DESIGN: This is the protocol of a phase IV multicenter clinical trial, randomized, controlled, crossover, open, which will compare the effect of two different formulations of paracetamol (effervescent or non-effervescent) in the blood pressure of hypertensive patients, with a seven weeks follow up. 49 controlled hypertensive patients will be included (clinical BP lower than 150 and 95 mmHg, and lower than 135 mmHg and 85 mmHg in patients with diabetes or a history of cardiovascular event, and daytime ambulatory measurements lower than 140 and 90 mmHg) and mild to moderate pain (Visual Analog Scale between 1 and 4). The study was approved by the ethics committee of the Fundació Jordi Gol i Gurina and following standards of good clinical practice. The primary endpoint will be the variations in systolic BP in 24 h Ambulatory Blood Pressure Monitoring, considering significant differences 2 or more mmHg among those treated with non-effervescent and effervescent formulations. Intention-to-treat and per-protocol analysis will be held. DISCUSSION: Despite the broad recommendation not to use effervescent drugs in patients with hypertension, there are relatively little studies that show exactly this pressor effect due to sodium in salt that gives the effervescence of the product. This is the first clinical trial designed to study the effect of effervescence compared to the non-effervescent, in well-controlled hypertensive patients with mild to moderate pain, performed in routine clinical practice. TRIAL REGISTRATION: NCT 02514538.

Perception of health and understanding of cardiovascular risk among patients with recently diagnosed diabetes and/or metabolic syndrome.

BACKGROUND: Cardiovascular (CV) disease mortality is increased in diabetes mellitus (DM) and metabolic syndrome (MS), conditions which share CV risk factors. AIM: The purpose of this study was to assess understanding of CV risk by patients with DM and/or MS diagnosed less than 1 year before and seen in primary care. Perception by these patients of their health state is also analysed. DESIGN: A multicentre, observational study in subjects diagnosed with DM diagnosed less than 1 year before and/or with MS, in whom agreement between CV risk perceived by patients and assessed by physicians was analysed. METHODS: Medical registry data and a survey of health status and perceived risk by patients and physicians. Agreement of patient perception of CV risk with perception of the physician in charge and with the CV risk established with clinical registry data was assessed. Self-perceived health status was also studied. RESULTS: A total of 150 physicians recruited 681 patients (71.5% with DM and 28.5% with MS) aged 60.8 ± 10.8 years (55.8% males). Good or excellent health were reported by 41.3% and 0.9%, respectively. Inability to give an estimate of CV risk was found in 39.8%. Agreement between the CV risks perceived by patients and evaluated by chart was poor: kappa index 0.145 (95% CI 0.101-0.189), p < 0.001. Agreement between CV risk perceived by patients and clinical data in the medical registry was weak: kappa index 0.165 (95% CI 0.117-0.213), p < 0.001. CONCLUSIONS: Patients with recently diagnosed DM and/or with MS have a poor awareness of their CV risk and 42.2% of them think that they have good or excellent health.

[Measurement of blood pressure in consultation and automated mesurement (BPTru(®)) to evaluate the white coat effect]. / Medida de la presión arterial en consulta y automatizada (BPTru®) para evaluar el efecto de bata blanca.

BACKGROUND AND OBJECTIVE: White coat effect (WCE) is one of the main bias that can affect office blood pressure (BP) measurement. Therefore, it is a factor must be considered in hypertensives to avoid mistakes in diagnosis and/or treatment. Employment of automated office BP (AOBP) devices could diminish that effect. METHODS: Two studies were designed with the objective of evaluating differences between routinely office and AOBP measurements. WCE was also assessed. First, the TRUE-ESP study included normotensive and hypertensive patients attending specialized consultations at Cardiology, Nephrology, Internal Medicine, Endocrinology and Family Practice. Second, the TRUE-HTA study included hypertensives attending a protocoled Hypertension Unit, with a trained staff. RESULTS: TRUE-ESP study included 300 patients, 76% being hypertensives. A significant difference between office BP and AOBP measurement (SBP/DBP 9.8±11.6/3.4±7.9 mmHg, P<.001) was observed. Percentage of patients gathering WCE criteria was 27.7%. TRUE-HTA study included 101 hypertensive patients. A significant difference between office BP and AOBP measurement (SBP/DBP 5.7±9.3/2.1±5.3 mmHg, P<.001) and activity period-ABPM (SBP/DBP 8.5±6.7/3.5±2.5 mmHg, P<.001) was observed. Percentage of WCE patients was 32.1%. CONCLUSIONS: Use of AOBP devices can contribute to decrease WCE and to improve accuracy of office BP measurement.

[Cardiovascular morbidity and mortality and electrocardiographic criteria of left ventricular hypertrophy in hypertensive patients treated in primary care]. / Morbilidad y mortalidad cardiovascular y criterios electrocardiográficos de hipertrofia ventricular izquierda en pacientes hipertensos en atención primaria.

UNLABELLED: FUNDAMENTALS AND OBJECTIVE: Electrocardiographic voltage criteria are the preferred method for diagnosis of left ventricular hypertrophy (LVH) in Primary Health Care (PHC). Several of these have been described as major adverse cardiovascular events (MACE) predictors. The aim of this study was to analyse the relationship between MACE occurrence in a cohort of hypertensive subjects in PHC and different electrocardiographic criteria recorded. PATIENTS AND METHODS: 265 hypertensive subjects attending PHC were randomly selected and followed up for 12 years. Standard 12-lead electrocardiograms were recorded at the beginning of the study. The occurrence of ischemic heart disease, heart failure, stroke, peripheral vascular disease, arrhythmia or cardiovascular death was considered as MACE. Electrocardiographic voltage criteria recorded were: Sokolow-Lyon, Minnesota code 3.1, Gubner and Ungerleider, Cornell voltage and Schillaci and Dalfó modifications. Data were analyzed using the life-table method and Cox regression models. RESULTS: 14,3% of patients lost to follow-up showed no differences in baseline characteristics from the rest of the cohort. The median follow-up was 10.1 years (IQR: 5.8-12.0). The cumulative survival rate was 53.5% (95% CI, 45.7-61.3%). The incidence of MACE was 5.85 (95% CI, 4.73-6.97) per 100 hypertensive patients-year. In the multivariate analysis none of the ECG criteria showed statistical association with the occurrence of MACE. CONCLUSIONS: No association has been found between different electrocardiographic LVH criteria and the incidence of MACE in a cohort of hypertensive patients followed-up in a PHC setting for 12 years.

Cardiovascular morbidity and mortality and left ventricular geometric patterns in hypertensive patients treated in primary care.

INTRODUCTION AND OBJECTIVES: Numerous hospital studies have shown that different left ventricular (LV) geometric patterns have different effects on cardiovascular risk. The aims of this study were to estimate the risk of major adverse cardiovascular events (MACEs) in hypertensive patients seen in primary care and to identify any association with LV geometric pattern. METHODS: In total, 265 hypertensive subjects attending primary care were randomly selected and followed up for 12 years. Those with cardiovascular disease, secondary hypertension, complete bundle branch block or electrocardiographic signs of ischemic heart disease were excluded. The LV geometric pattern was characterized as either concentric hypertrophy, eccentric hypertrophy, concentric remodeling or normal. A MACE was the occurrence of ischemic heart disease, heart failure, stroke, peripheral vascular disease, arrhythmia or cardiovascular death. Data were analyzed using the life-table method and Cox regression modeling. RESULTS: Although 14% of patients were lost to follow-up, their baseline characteristics were similar to those of patients who completed the study. The cumulative survival rate was 56.3% (95% confidence interval [CI], 49.8%-62.8%). The incidence of MACEs was 4.67 (95% CI, 3.79-5.55) per 100 subject-years. Moreover, the incidence was similar in the four LV geometric pattern groups (P=.889). Only age (hazard ratio [HR]=1.03; 95% CI, 1-1.05) and the presence of diabetes at study entry (HR=1.67; 95% CI, 1.03-2.69) were associated with an increased risk of a MACE. CONCLUSIONS: In the study population, only age and diabetes at study entry were associated with the occurrence of a MACE. There was no evidence for an association between MACEs and the LV geometric pattern.

[Is the action taken by Catalonian primary care doctors adequate in view of the insufficient reduction in blood pressure levels in hypertensive patients? DISEHTAC-2001 study]. / Es adecuada la actitud que adoptan los médicos de atención primaria en Cataluña ante la insuficiente reducción de cifras de presión arterial en los pacientes hipertensos? Estudio DISEHTAC-2001.

OBJECTIVE: To determine the attitude to therapy of primary care staff in view of the lack of reduction in blood pressure. To describe the most commonly used antihypertensives. DESIGN: Descriptive, longitudinal, retrospective study during the year 2001. SETTING: Primary care, Spain. PARTICIPANTS: We analysed 990 hypertensive patients from 12 health centres picked from the 31 participants in the DISEHTAC-1996 study. METHODS: Age, sex, weight, and height were analysed, along with blood pressure values throughout the year 2001, therapeutic attitude (increase/replacement/combination) with poor control (more than 2 consecutive visits with blood pressure>139 and/or 89 mm Hg), screening and prevalence of cardiovascular risk factors (CVRF), and drugs used. RESULTS: There were 58.9% females; mean age: 65.4 (13.01) years, and 43.8% received 2 or more antihypertensives. The most common antihypertensives prescribed were diuretics (47.6%), and angiotensin-converting enzyme (ACE) inhibitors plus diuretics was the most used combination (22.1%). When there was poor control, some change in treatment was made in 76.8% (95% confidence interval [CI], 73.6-80) of cases. The most common was a combination of drugs (49.6%). The expected action was more frequent in those over 65 years and with a grade I of arterial hypertension (systolic blood pressure [SBP] between 140-150 and diastolic blood pressure [DBP] between 90-99 mm Hg (P<.001). CONCLUSIONS: Combined therapy is used in almost half of hypertensive patients, with the most common action being a drug combination.

[Prevalence of chronic kidney disease in hypertensive patients under treatment at primary care health centres in Spain and the monitoring of their blood pressure: the DISEHTAE Study]. / Prevalencia de enfermedad renal crónica en los hipertensos seguidos en los centros de salud de España y grado de control de su presión arterial (estudio DISEHTAE).

OBJECTIVE: To establish what proportion of hypertensive patients being treated in the primary care health centres of Spain have diminished renal function, and to ascertain their level of blood pressure (BP) control. DESIGN: Descriptive, cross-sectional study, based on an external audit of clinical charts. SETTING: Primary care health centres in 14 autonomous regions. PARTICIPANTS: A total of 6,113 charts of hypertensive patients from 107 primary care health centres were checked. The selection of primary care health centres and charts was randomized. MAIN MEASUREMENTS: Creatinine and BP figures of the patients included were analyzed. Chronic kidney disease was defined as a glomerular filtration rate (GFR), as calculated by the equation developed by the Modification of Diet in Renal Disease (MDRD) Study, at under 60 mL/min per 1.73 m(2) of body surface area. A good level of BP control was defined as having figures lower than 130/80 mm Hg. RESULTS: Of all patients, 25.7% (95% CI, 24.3-27.2) had a diminished GFR. Of these, 19.1% (95% CI, 16.6-21.9) had a good level of control of systolic BP, 49.9% (95% CI, 46.6-53.2) had a good level of control of diastolic BP, and 15.2% (95% CI, 12.9-17.8) had a good level of control of both. CONCLUSIONS: A considerable proportion of hypertensive patients under treatment in the primary care health centres of Spain have a diminished GFR. Only 1 in 6 of these have their BP under control.

[Follow-up and monitoring of hypertension. Is this performed the same in the autochthonous and immigrant populations?]. / Seguimiento y control de la hipertensión arterial. Se efectúa igual en la población autóctona y en la inmigrante?

OBJECTIVES: To evaluate the degree of control of blood pressure (BP) in the autochthonous and immigrant populations and to find the variables linked to good control. DESIGN: Cross-sectional, observational study. SETTING: Urban primary care team, Spain. PARTICIPANTS: All patients with hypertension seen between 1/1/2000 and 1/7/2005 and whose origin was known: 1.063 patients in all, 931 autochthonous and 132 immigrant ones. MAIN MEASUREMENTS: The main variable was hypertension control the last time BP was taken (BP

[Home blood pressure self-monitoring. Influence of the mean calculation used on the diagnosis of white-coat hypertension]. / Automedida de la presión arterial domiciliaria. Influencia del sistema de cálculo de la media en el diagnóstico de la hipertensión de bata blanca.

OBJECTIVE: To describe the variations in the diagnosis performance of home blood pressure self-monitoring (hBPSM) with different methods for mean calculation, in order to diagnose white-coat hypertension (WCH). DESIGN: Multi-centre, descriptive, and comparative study to assess the diagnosis performance of a test method. SETTING: Four primary health care centres. PARTICIPANTS: A total of 157 recently-diagnosed, untreated patients with mild-moderate hypertension took part in the study. METHODS: The results obtained with hBPSM (3 consecutive days with readings in triplicate, morning-night) were compared with a "gold standard" out-patient blood pressure reading (OutBP). RESULTS: Systolic and diastolic BP values of the first day and first reading (morning-night) were higher than the remaining days and readings (linear trend P< .001). Results in hBPSM diagnostic performance using all readings to calculate the mean were: sensitivity (S), 47.6%; specificity (Sp), 77.4%; positive and negative predictive values (PPV and NPV), 58.8% and 68.6%, with positive and negative probability coefficients (PPC and NPC), 2.10 and 0.67. When readings with greater patient alarm reaction (first day and first reading, morning-night) were removed, greater values of S (61.9%) were obtained, albeit at expense of an excessive loss in Sp (64.5%) and without improvement in PPC (1.74). CONCLUSIONS: The diagnostic performance of hBPSM in WCH was low and failed to improve with the use of different systems to calculate mean BP.